Failure to Perform Hand Hygiene and Conduct Documented Infection Control Surveillance
Penalty
Summary
The deficiency involves the facility’s failure to implement infection prevention and control practices during the care of a resident with an indwelling urinary catheter and nephrostomy tube, as well as a failure to conduct documented infection control process surveillance. Resident #6, who had intact cognition with a BIMS score of 15, had diagnoses including hypertension, kidney failure, blocked urine flow, and non-Alzheimer’s dementia, and required assistance with draining his catheter bag and nephrostomy tube. The resident had an order for Enhanced Barrier Precautions related to catheter use and had a history of a UTI and an indwelling catheter with pus noted around the catheter. During a continuous observation, a CNA (Staff C) donned an isolation gown, gloves, and an ear loop mask in the hallway without performing hand hygiene before entering the resident’s room, despite an Enhanced Barrier Precautions sign directing that everyone must clean their hands before entering and when leaving the room. Once inside, the CNA moved the resident’s bedside table, assisted the resident in moving his legs off the bed, and proceeded to empty the urinary catheter bag into a drainage cylinder placed on the floor in a plastic bag. After emptying and cleaning the catheter spigot with an alcohol swab, the CNA moved the cylinder to the counter, then removed her gloves and put on new gloves without performing hand hygiene between these tasks. The CNA then placed the nephrostomy drainage cylinder on the floor in a plastic bag, opened the nephrostomy bag spigot, emptied it into the cylinder, wiped the spigot with an alcohol swab, measured the output, and emptied it into the toilet. She subsequently removed her gloves, tied the trash, replaced the trash bag, and only then performed hand hygiene with soap and water. The CNA later acknowledged she should have performed hand hygiene before donning PPE and between emptying each collection bag, and the DON confirmed staff should perform hand hygiene between glove changes and follow catheter care policy. Additionally, the Administrator reported that while she performed infection prevention surveillance audits, she did not document them, and there was no documented process surveillance to capture staff compliance with infection prevention practices, despite a facility policy stating that the infection preventionist collects data to determine the effectiveness of preventative measures when such precautions are implemented.
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